Question: Are paramedics in Ontario authorized to adhere to a person's DNR wishes documented on a completed 'CCAC Plan of Treatment' as an alternative to a completed 'DNR Confirmation Form’?

This is a challenging scenario for paramedics to be in. As per the BLS Standards, the Do Not Resuscitate standard is to be followed only when a valid MOHLTC DNR Confirmation is presented to the paramedics. In these situations, paramedics will start resuscitation and attempt to contact a base hospital physician for further direction. A working group at the provincial level has recently been formed to explore other potential DNR methods that may be utilized in the prehospital setting.

Question: When the Ministry of Health's DNR forms are filled out, can the section where the patient's name goes have a sticker from the hospital with the patients name/health card #/DOB, etc. instead of having the name printed or does that make the form invalid. The form specifically states the patient’s name should be printed clearly. I wasn't sure if the ID sticker was something we could accept instead or if that section can only be filled out by hand.

Question: In a setting where you arrive on scene and you are presented with a patient who is unconscious and is hypotensive, the patient has a valid DNR. Can you still administer fluids to this patient or does that fall under the same category as inserting an OPA/NPA and BVM to a patient with a DNR?

Situations involving end of life can be very complicated, and it’s very hard, if not impossible, to capture a patient’s wishes for their care on a single form.

The ideal scenario would be that the patient would have some more specific advanced directive outlining their wishes in terms of IV Fluid. IV Fluid is not listed as a therapy that paramedics are not to provide a patient with a valid DNR and could be considered in the hypotensive patient as long as the other conditions of the medical directive are met. As an example a patient in septic shock could have an altered LOC from poor perfusion and despite the DNR benefit from IV fluid.

Question: How is the DNR standard in the BLS PCS reconciled with this statement in the ALS PCS: "if a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated)."

Obviously the ideal situation is that the patient has the DNR confirmation form and there are no issues. The issue comes up with regards to verbal DNRs issued by a capable patient or SDM (that are reasonable), or in such cases where the patient has a DNR, living will or other advanced directive that specifies the patients wishes, but no prehospital DNR form. Is this form not redundant provided there is a reasonable indication that the patient does not wish to be resuscitated or have aggressive life sustaining therapies delivered?

How can the BLS PCS DNR standard be reconciled with the ALS PCS regarding honouring a prior capable wish when the provider is made aware of such wish (provided its reasonable)? Especially given that in nearly ever other case, a directive in the ALS PCS over-rides the BLS-PCS. Given that this issue is not nearly as cut and dry in reality, or in any other healthcare setting, as it seems to be made out to be in EMS in this province what is the situation with regards to this? Especially given that end-of-life issues are increasingly common, the issue is not going to disappear. There are many other provinces that use a similar wording or philosophy to that mentioned in the ALS-PCS under consent and capacity.

Answer: Thank you for your question. It is a confusing area of practice. The short, straight forward, policy answer is that paramedics provide resuscitation procedures to everyone who requires them UNLESS the patient has a signed Ministry of Health / Fire Marshall approved DNR form indicating there is a DNR plan in place or there is a signed inter-facility DNR order. If the form is not available to be checked then resuscitative measures should be started until the form is produced.

While we wish to follow a person’s wishes regarding their end of life, the dilemma is that resuscitation in cardiac arrest is a time sensitive situation. The default expectation is to begin resuscitation if someone calls 911 and requests assistance. A paramedic does not have the luxury of spending time to sort out what the person’s wishes are, who is the designated alternate decision maker is if the person is not capable of indicating their own wishes etc.

As you correctly point out, the real world is not so clear. People frequently don’t discuss their end of life wishes. When they do, they often don’t write down their wishes. They seldom do so on an “approved” form. Likely the person or their family doesn’t know such a form exists. The form requires substantial effort to obtain.

The problem is what to do; when the form does not exist, when it can’t be readily produced, or when a family member is clearly stating the person does not want resuscitation. It is tempting to follow the direction of the family member but this action does not comply with the standard.

We suggest the following compromise. If an approved form is not readily produced to examine and bystanders indicate the patient does not wish resuscitation then CPR or other resuscitative measures should begin. One of the paramedics should obtain the details and explain that they are obliged to begin until the situation is clarified. This information should be relayed in a patch to the Base Hospital physician and discussed. In most cases the paramedic will be given a cease resuscitation order and the resuscitation can be stopped.

While this is not an ideal solution, this course of action balances the legal obligations and moral claims to respect the autonomy and wishes of the patient. Everyone should be encouraged to discuss their end of life wishes with their family and to document their wishes appropriately.

Question: Are we allowed to accept photocopied DNR? I have heard several discrepancies on this question.

Answer: Yes, you are allowed to accept a photocopied DNR, as long as it is a photocopy of a valid DNR: with all required fields completed prior to the copy being made. For full details on the mandatory completed fields please see the DNR standard bulletin on our website:

Question: I have been to a few calls where the patient does not have a DNR, but the death is expected and family does not want CPR or other interventions. The family will make statements like "we don't want CPR" or “they wouldn't want CPR", etc. Do we initiate the CPR and Defibrillation protocols until we can get hold of the BHP or do we run the call and transport regardless of family request?

Thanks for the question. This is very similar to another ASKMAC question from 2012. The process for a paramedic to withhold initiating resuscitation is clearly outlined in the Do Not Resuscitate (DNR) Standard training bulletin.

This exact situation is reviewed in the Training Bulletin produced by MOHLTC in Appendix 2 named ironically Frequently Asked Questions.

Question 17 on page 26 states: “For the paramedic or firefighter to not perform CPR on a patient who is in respiratory or cardiorespiratory arrest, he/she MUST receive a fully completed DNR Confirmation Form. This Form is the only directive that gives permission to paramedics and firefighters to not perform CPR on patients who have a DNR order and have experienced respiratory or cardiorespiratory arrest”.

Question: There is some confusion about patients that have a valid DNR, and are very sick requiring transport. It makes sense that many of the ACP skills might not be utilized on these patients, and CPAP would be a PCP skill. There are cases where the family changes their mind on a DNR, and cases where the status is not clear. There are also other cases where a patient may be a trauma and have a valid DNR where they may need a needle decompression, but not necessarily cardiac arrest needing CPR or intubation. Is it OK for ACPs not to attend valid DNR patients?

It is difficult to envision every scenario. The CTAS level and sickness level of the patient should be the guide as to the responsibilities of the attending medic as it would be in any other case regardless of DNR status. Indeed these patients may have a stroke, trauma, or other medical condition that may benefit from more advanced skills. There is also the possibility of utilizing narcotic pain medication for compassionate palliative care. A change in the DNR status by attending family members may also be more easily dealt with, although hopefully this will be very infrequent with better communication surrounding the DNR process.

Basically, when considering crew attendance and responsibilities these cases should be approached exactly the same as any other case depending upon the clinical situation and judgement of the crew as outlined in the policy. In practice as a guide as we have done for years the ACP will attend on any CTAS 1 or 2 return transport.

Question: I was told by a physician that a DNR becomes void with a suicide attempt. I was wondering how we should approach this situation.

Answer: This is an interesting question and hopefully a rare clinical situation. Suicide specifically is not addressed in the MOHLTC Training Bulletin on the DNR Standard.

One of the first issues with this clinical scenario (DNR/Suicide patient) would have to be: who is it that activated 911? If there is a family member or other individuals who are present on scene demanding that CPR be initiated, then this is addressed by the MOHLTC training Bulleting on the DNR Standard.

In Section 1 A point #2 if the DNR Standard it states: A paramedic WILL initiate CPR on a patient who has experienced a respiratory or cardiorespiratory arrest when the substitute decision maker (SDM) has rescinded a valid DNR confirmation form by stating he/she wishes CPR to be performed or there is confusion as to who the SDM is and/or one or more people present at the time is demanding that CPR be initiated on the patient.

If there are no bystanders present on scene but somehow 911 was activated (perhaps by the patient themselves prior to self-harm) the other consideration would be to patch to the BHP for further direction in this rare situation.

Question: We had our recert this week and I have a question about DNR patients. In the pocket book it says that a patient will get epi IM if they have a history of asthma and BVM ventilation is required. So I am wondering, if a DNR patient does not receive a BVM under any circumstance and an asthma patient with a valid DNR who started off just slightly SOB became severe and required a BVM would they still be eligible for epi? In other words does "required" mean that yes it is required due to the severity of SOB, but due to the fact they have a DNR they don't actually get the BVM, can they still receive the epi, which is not contraindicated on the DNR validity form? Thanks in advance.

Answer: Thanks for your question. Hopefully a severe asthma exacerbation requiring BVM ventilation and therefore epinephrine IM in a patient with a valid DNR is a rare situation.

The DNR confirmation form identifies that epinephrine for anaphylaxis remains indicated for patients with a DNR in section 2 for the purposes of providing comfort (palliative) care. It also stipulates that this list of what is acceptable under section 2 is limited to those interventions and therapies so in theory epinephrine for this scenario is not contraindicated.

Epinephrine as a vasopressor is contraindicated in patients with a DNR as per section 1 however in the clinical scenario you describe above, the patient does not require epinephrine for that indication.

As you have correctly identified, the SWORBHP Medical Council has previously directed that BVM ventilation is contraindicated in DNR patients as this represents artificial ventilations and this as well is listed as contraindicated in section 1 of the DNR form.

Finally, your Bronchocontriction Medical Directive does indicate that BVM ventilation is required for a paramedic to administer epinephrine however one could argue that BVM could be required yet not provided (since contraindicated by the DNR) thus meeting the indication of “required”.

The bottom line for this rare situation would be to NOT administer the epinephrine IM in isolation to a DNR patient requiring BVM ventilation but not receiving it due to limits imposed by a valid DNR. IM Epi for asthma at best is moderately effective and most likely of little benefit as an isolated intervention.

As with any rare situation not explicitly covered by the Medical Directives, patching to the BHP for direction should be considered.

Question: I was just wondering if we have a patient with a valid DNR are we still allowed to Bolus if they fit our protocol or is this considered an advanced life saving technique?

Answer: Thanks for the question. In terms of the DNR Standard, IV fluid is not listed as being contra-indicated or forming part of the cardiopulmonary resuscitation as defined in section 1. With this in mind, it is recommended that IV fluid be administered when appropriate for patients with or without a valid DNR.

As an example, consider the patient who is hypotensive from sepsis. IV fluid resuscitation may be truly life saving for this patient and should be provided.

It is essential however to review local policies with individual facilities as to the extent of limitations of care as requested by patients. In some situations, you may be confronted by specific local documentation which would request no IV therapy (however this should be the minority of cases).